Nursing care defects registration

Medical care defects refers to medical personnel in medical activities, in violation of health care management laws, administrative regulations, departmental regulations and diagnosis and treatment of norms, routines and the occurrence of diagnosis and treatment of negligent behavior. The cause of its occurrence may be the work of medical personnel negligence, may also be caused by the patient, such as: medical personnel to ask about the history of the patient deliberately concealment and so on. According to the degree of its impact on the patient, can be divided into light, medium, heavy three degrees. Severe defects: Seriously affect the therapeutic effect or cause damage to important tissues and organs to dysfunction; even cause disability, death and other serious adverse consequences. Moderate defects: affecting the efficacy of treatment, prolonging the course of treatment, causing curable damage to tissues and organs; or violating the operating procedures, increasing the patient's pain and medical costs, but without serious consequences. Mild defects: no effect on the patient or a slight effect on the patient without adverse consequences. [1] Definition criteria of medical care defects 1, medical record writing defects Severe defects (1) the main complaint, history of current illness, physical examination has important omissions that cause diagnostic errors or affect the treatment, resuscitation; (2) patients in critical condition for 24 hours, patients with serious illness for 2 days without a superior physician checkups, no record of the course of the disease; (3) death of the medical record of the death of the death of the resuscitation, death of the record of the discussion, etc.; (4) lack of the first page of the medical record, inpatient medical record, hospitalization records, records of the course of one; (4) lack of medical records of the first page, hospitalization medical record, hospitalization records, medical records, medical records; (5) the patient is not in a hospital, hospitalization records, medical records, medical records, medical records, medical records, medical records. (5) Surgical patients without pre-operative conversation signature records, anesthesia records, surgical records, pre-operative and intra-operative care records, post-operative medical records, post-operative medical advice of one. (6) Disabled surgery, major surgery performed for the first time, or surgery without the signature of the patient's family without the approval of the hospital director. Moderate defects (1) absence of one of past history, personal history, family history, menstrual and reproductive history; (2) absence of superior physician's opinion within three days of hospitalization or before surgery; (3) absence of stage summary for more than 30 days of hospitalization; (4) absence of consecutive course records for newly admitted patients and three days after surgery; (5) absence of diagnostic basis and diagnostic and therapeutic plan for the first course of records; (6) absence of records for specialized patients; (7) absence of records for patients who have been transferred to another department and received by another department; (8) absence of records for patients who have been transferred to another department and received by another department; (9) absence of records for patients who have been transferred to another department and received by another department. (7) No record of transferring and receiving patients; (8) Missing consultation and examination sheets; (9) Lack of shift handover records, records of room visits by supervising physicians and records of special treatments; (10) Critically ill patients who are not given critical care in a timely manner or whose critical care orders are stopped prematurely. Mild defects (1) the first page, frieze columns and related forms are not filled out; (2) the entire medical record without the signature of the supervising physician; (3) more than three consecutive days (chronic diseases for a week) without a record of the course of the disease; (4) medical terminology is inappropriate or there are obvious textual errors; (5) the order of the medical record or the checklist is not standardized paste. 2, Diagnostic defects Severe defects (1) Diagnostic errors or omissions of major diseases, resulting in delayed treatment; (2) delayed diagnosis and treatment of difficult, acute, or serious cases without consulting a superior physician or consulting a doctor; (3) damage to vital organs due to the implementation of diagnostic measures; (4) incorrect diagnosis due to the reliance on the examination report of the medical department; (5) delayed diagnosis due to failure to carry out critical examination measures in a timely manner. Moderate defects (1) Lack of routine drugs or equipment failure that leads to delayed diagnosis; (2) Undiagnosed non-troublesome diseases for more than a week that are not reported according to the diagnostic standard; (3) Main diagnosis is established, but the diagnosis of complications is omitted and affects the treatment; (4) Failure to carry out diagnostic measures that cause pain to the customer; (5) Insufficient basis for diagnosis of the main diseases that leads to inaccurate diagnosis. Mild defects (1) difficult cases without timely consultation, but does not affect the treatment; (2) secondary diagnosis or comorbidities missed, but does not affect the treatment; (3) excessive use of unnecessary auxiliary tests; 3, treatment defects Severe defects: (1) the principle of treatment and the key therapeutic measures are wrong; (2) treatment errors or improper use of medication to cause severe pain or damage to the patient; (3) the diagnosis of serious patients is clear, but the timely adoption of therapeutic measures to increase the patient's pain. (3) Timely adoption of therapeutic measures for patients with serious illnesses, resulting in increased pain and suffering. (4) The patient's condition deteriorates during hospitalization, but the doctor fails to detect it in time, and then misses the opportunity to rescue the patient, resulting in adverse consequences. Moderate Defects (1) Inappropriate use of medication or handling errors affect the efficacy of treatment, but do not cause damage; (2) non-serious patients are not diagnosed in a timely manner after the diagnosis is made; (3) prolonged treatment due to insufficient preparation of conventional medicines or equipment. Mild defects (1) Increased side effects due to irrational use of medication; (2) Inadequate adjuvant therapy that does not affect the efficacy of the treatment; (3) Misuse of unnecessary medications or treatments; (4) Correct therapeutic measures that are not approved in accordance with standardized procedures. 4,Resuscitation defects Severe defects (1) untimely resuscitation leading to delayed resuscitation; (2) misjudgment of the condition or failure to operate in accordance with the resuscitation routine errors; (3) the need for multidisciplinary collaboration in the resuscitation of inter-disciplinary cooperation is ineffective to affect the effectiveness of the resuscitation; (4) resuscitation of medicines, equipment, energy barriers to affect the effectiveness of the resuscitation; (5) resuscitation of the process of operating improperly resulting in damage to vital organs; Moderate defects (1) the failure of timely or ineffective measures; (1) the failure of resuscitation or measures; (4) treatment measures are correct, but not approved in accordance with the standard procedures. Moderate defects (1) untimely or ineffective rescue; (2) poor operation of equipment affecting the rescue; (3) poor cooperation between related departments in the rescue; (4) tissue damage caused by improper rescue operations. Slight defects (1) Resuscitation cases without the guidance of a superior physician; (2) Resuscitation records and medical advice is not standardized, imperfect; (3) Resuscitation drugs and equipment is not properly prepared, but does not have a direct impact on the effectiveness of the resuscitation. 5, surgical defects serious defects (1) surgery, site, time selection errors lead to surgical failure; (2) improper surgical operation damage to vital organs, affecting the physiological function of the patient; (3) violation of the operating procedures directly or indirectly caused by hemorrhage shock; (4) improper surgical operation or insufficient preoperative preparations can not achieve the purpose of the operation; (5) postoperative body left non-therapeutic foreign body; (6) during the operation, encountered complex situations, not in time, and not to achieve the goal. (6) Failure to report to the supervisor or consult with the doctor in case of complicated situations; (7) Failure to notify the patient and his/her family of the need to change the surgical procedure due to unforeseen circumstances during the operation, and disputes arise after the operation. Moderate Defects (1) Rough surgery causing excessive tissue damage without sequelae; (2) Improper operation resulting in excessive blood loss without causing hemorrhagic shock; (3) Improper operation resulting in infection, hematoma, fistula, sinus tract formation and affecting healing; (4) Extraordinary operation in violation of surgical classification management; (5) Elective surgery without justifiable reasons for the preoperative waiting time of more than 5 working days. Minor defects (1) foreign body left in the incision and affect the healing; (2) septic foci of incision and drainage is not good and need to expand the drainage or delayed healing; (3) improper use of instruments caused by the patient's injuries; (4) postoperative wound treatment due to improper wound healing as scheduled. 6, Nosocomial infection control defects Severe defects (1) Nosocomial infections and food poisoning during hospitalization (not in the incubation period); (2); (3) Three or more infections of the same bacterial group in a short period of time due to improper disinfection. (4) Serious infectious diseases such as AIDS, Hepatitis B, Hepatitis C, etc. due to blood or fluid transfusion. Moderate deficiencies (1) Failure to isolate and sterilize patients with legally infectious diseases, but no cross-infection; (2) Delayed healing of aseptic wounds due to infections in more than 0.5% of cases; (3) Secondary infections due to improper use of medication; (4) Blood-borne infections due to blood or fluid transfusion. Minor defects (1) Inadequate sterilization of instruments, dressings, and air, but not yet causing infections; (2) Infections occurring during hospitalization. (3) Dirt and sewage from the laboratory and operating room are not discharged in accordance with the standard. 7, nursing defects serious defects: (1) nursing monitoring errors, checking laxity caused by the wrong diagnosis and treatment, resulting in adverse consequences; (2) AWOL and delayed diagnosis and treatment of care, resulting in serious consequences; (3) violation of aseptic technology, resulting in serious infections; (4) infusion (static) leakage caused by necrosis of the tissue up to 3x3cm or more; (5) improper nursing care occurred in the fall, suffocation, fainting and causing adverse consequences; (6) improper care of the fall, suffocation, fainting and causing adverse consequences; (6) the fall, fainting and causing adverse consequences; (7) the fall, suffocation, fainting and causing adverse consequences; (8) the fall, suffocation, fainting and causing adverse consequences; (9) the fall, suffocation, fainting and causing adverse consequences; (10) the fall, fainting and causing adverse consequences. (6) Delay in diagnosis, treatment and nursing work due to inattentive shift handover, resulting in adverse consequences; Moderate defects: (1) Improper nursing care resulting in bedsores, burns, frostbite, poor drainage of body cavities; (2) Delay in surgery, examination and treatment time due to failure to make preoperative preparations on time; (3) Omission or inaccuracy of various records affecting the diagnosis and treatment of the patient; (4) Loss of specimens affecting the diagnosis and treatment of the patient. (4) Loss of specimens affecting diagnosis and treatment . Mild defects: (1) violation of rules and regulations and increase customer suffering; (2) all kinds of records are inaccurate, but does not affect the diagnosis and treatment; (3) specimen retention or preoperative preparation in a timely manner, has not yet affected the diagnosis and treatment; (4) aseptic technology operation is not skilled, resulting in patients with mild infections; (5) patients with critical conditions without a plan of care. 8, anesthesia defects serious defects (1) anesthesiologists clinically rescue clients, forgetting important equipment, medicines affect the rescue. (2) Anesthesiologists who neglected their duties during the operation and caused a respiratory or circulatory arrest of a patient, but the patient recovered successfully after rescue. (3) Pneumothorax caused by anesthesia puncture without proper operation. (4) Anesthesiologists' irresponsibility resulting in anaerobic supply or carbon dioxide retention. (5) The anesthesiologist on duty stops, delays, or excuses the surgery without any reason, or leaves his/her duties without authorization, which affects the timely conduct of the surgery. Moderate defects (1) Low-level intrathecal anesthesia that is not performed in accordance with the usual procedures, resulting in a high plane and respiratory depression, which is treated without adverse consequences. (2) Epidural anesthesia not performed in accordance with the usual procedures, resulting in puncture of the dura mater or the anesthesia catheter being forgotten and brought back to the ward. (3) The patient's teeth are loosened, dislodged, or the pharynx is severely damaged due to anesthesia intubation not being performed in accordance with the usual practice; Mild defects (1) Incomplete anesthesia, which seriously interferes with the surgical procedure. (2) Failure of anesthesiologist to prepare the patient for anesthesia within 30 minutes after the notification of emergency surgery without any special reason. (1) Misuse of unsterilized items in the operating room due to a lax shift handover. (2) Falling of a car or bed before or after transporting a patient to or from the operating room. Moderate Defects (1) Failure to check and count dressings and instruments before closing a body cavity, resulting in prolongation of the operating time by more than 30 minutes. (2) Inadequate preparation of major surgical instruments and medications in the operating room, which affects the operation. Slight defects (1) Inadequate fixation or placement of the surgical patient and inadequate protection of the patient's body, resulting in skin pressure injuries or blisters. (2) Slight burns caused by the use of hot water bags or electrodes due to a lack of responsibility. 10. Defects in the Blood Transfusion Department (Blood Bank) Severe defects (1) A report was issued for an error in a blood cross-test; (2) Blood was issued to a customer in error, but the error was detected and handled in a timely manner. Moderate Defects (1) Wrongly issued blood that is not fed to the customer; (2) Failure to supply blood within 30 minutes after receiving a transfusion request from a critical or rescue patient without any reason, which affects the rescue; (3) Waste of blood of 200 ml or more due to expiration or damage of the package due to lack of sense of responsibility. Slight defects (1) loss of blood specimens need to be redrawn; (2) due to damage to the packaging caused by the waste of blood less than 100 ml; (3) blood vials (bags) on the labeling errors (name, blood type) or mislabeling, has been issued but not the user.